Nurses in neurosurgical settings often have to manage confused, agitated, uncooperative and sometimes aggressive patients who may attempt to leave the safety of the ward, climb out of a bed or chair, or remove tracheostomy tubes, invasive drains and intravenous or central lines. These behaviours can severely compromise patient safety.
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Catheryne Waterhouse, MSC Nursing, PGCE, BA, is lecturer/practitioner, neuroscience unit, Royal Hallamshire Hospital, Sheffield
Similarly, managing patients with challenging behaviour can be a daily occurrence on many neuromedical wards. This can include dealing with postictal epileptic patients or those experiencing adverse reactions to Parkinson’s disease medication.
The National Benchmarking Group, which is affiliated to the British Association of Neuroscience Nurses (BANN), has explored issues related to the restraint of patients. The BANN is a relatively small organisation with 400 members representing neuroscience units across the UK. Many have expressed concerns about the management of confused and disoriented patients, specifically in relation to their professional obligations to ensure patient freedom, dignity and autonomy, and to recent amendments to the Mental Capacity Bill (NMC, 2002; Reigle, 1996).
Initially, a group of nurses from neuromedicine, neurosurgery and neurocritical care, who had an interest and experience in managing patients with challenging behaviour, formed a working group to review the literature and discuss guidelines for good practice. The aim was to develop guidelines and advice for staff in specialist areas on how to manage challenging behaviour while maintaining patient safety and dignity.
Definitions of restraint
The dangers incurred as a result of restraining patients are clear and well documented. A small yet significant number of patients have died due to accidental strangulation and asphyxiation following physical and chemical restraint (Tschudin, 1992). In addition, restraint has been correlated with poor patient outcomes, higher mortality and morbidity rates, increased hospitalisation, nosocomial infections and pressure ulcers and increased levels of confusion (Maccioli et al, 2003; Martin, 2002; Ashcroft-Simpson, 1999).
Stilwell (1991) conducted a comprehensive critique on the use of restraints and cited several factors that influence nurses’ decision-making. Overwhelmingly they stated that the most pressing problems were the shortfall in nurses available to manage unrestrained patients against a background of possible litigation from those who might injure themselves or others (Dimond, 2002).
Legal issues in restraint
The courts are quite clear that, with limited exceptions such as reasonable self-defence, reasonable chastisement or reasonable everyday contact, to touch someone or cause someone to be touched against their will is unlawful. Everyone has the basic right to be free from the use of unauthorised force that could restrict their speech or their movement. According to the Human Rights Act (1998), anyone who is restrained is therefore suffering from a denial of their basic human rights, unless they are subject to legal detention.
The management of agitated and confused patients, when it is obvious that to allow them complete autonomy could be detrimental to their own welfare, demands a highly skilled approach (Dimond, 2002; Taggert and Lind, 1994). This poses a difficult ethical and moral dilemma for nurses, who are faced with a conflict between the patient’s right to independence and their own code of conduct and the law of negligence and duty of care (NMC, 2002; Jones, 1988).
The national neuroscience benchmarking group has formulated its own standards and guidelines for the management of confused, disorientated and agitated patients.
These emphasise the importance of conducting a risk assessment of vulnerable patients before instituting short-term restraints. They also require staff members to be informed of the risks and benefits of restraining and the use of available alternatives.
Education on issues related to restraint is emphasised. Ideally this should include training on managing aggressive and difficult patients. Staff should also be given information on the ethical and legal perspectives of the decision-making process with regard to compassion and the basic principles of respect for the patient (Beauchamp and Childress, 1994).
Finally, as with any in-house training, support and coping strategies must be provided, aimed at helping nurses to cope with their concerns about the use of restraints. The majority of nurses feel uncomfortable about, for example, placing a bed table in front of a patient, which they know will prevent that patient from mobilising (Robbins et al, 1987). Nurses are aware of their legal, moral and professional responsibilities, but with few available alternatives they are forced to continue implementing the same practices.
The Declaration of Human Rights (1948), and the European Convention on Human Rights (1950) both state that restraint is only justified providing it does not involve inhumane or degrading treatment. But how does this relate to nurses’ clinical practice? If the law states that the act of restraining patients is an infringement of their human rights, and guidelines have been developed to support that principle, how is it possible for nurses to ensure these guidelines are sustained and enforced? A right that lacks value and cannot be implemented in practice is of no use to anyone.
It is clear that further work is required to reduce reliance on physical and chemical restraints in neuroscience settings. Nurses need to think and act more creatively in order to provide alternative measures of addressing challenging behaviour in their patients and to create a culture in which the use of physical and chemical restraint on patients is only considered after all reasonable alternatives have been exhausted.
Practitioners should perform a risk assessment before any form of restraint is considered or applied to patients whose behaviour is putting themselves or others at risk or compromising care. Some of the key recommendations from the benchmarking project include:
- Restraints should only be used when positive, non-restrictive procedures have failed to produce the desired behavioural change;
- The agreement of the patient must always be sought. Patients must be informed of the benefits that they might derive from the measures in question;
- The patient and/or the patient’s family/representative should be involved in discussions about the rationale for any use of restraint, desired outcomes and ethical and legal considerations;
- Intervention from the family should always be considered as a possible alternative to restraint;
- Any factors that predispose the patient to challenging behaviour, such as environment, time of day, pain, hunger or toileting should be considered and, where possible, addressed;
- The restraint measures that are applied should be the least restrictive necessary to achieve the desired effect;
- The use of restraint must be monitored and documented to evaluate its effectiveness;
- Any necessary measures should form part of the care plan for the patient;
- The use of less restrictive interventions should be attempted periodically and the results should be documented;
- Commercially produced restrainers should be consistently used - the use of bandage and tape is not acceptable;
- Visual observation must be made at least every 20 minutes while restraint is in use;
- The patient must be released from the restraint at least every two hours and the requirement for that restraint re-evaluated;
- Staff should be trained in the implementation and monitoring of the recommended interventions. Clear guidelines for staff should minimise the risk of mistakes being made;
- Whenever possible factors that cause the patient to behave in a way that results in the need for restraint should be treated and eliminated. It is essential for staff to fully assess and understand each patient’s history in order to determine why restraints have been used.
- This article has been double-blind peer-reviewed.